New Zealand's weekly publication The Listener recently published an article on the use of antidepressant drugs in New Zealand. These drugs are also known as selective serotonin re-uptake inhibitors (SSRIs), Tricyclic antidepressants (TCAs), and Monoamine Oxidase Inhibitors (MAOIs).
The SSRI medicines available in New Zealand are:
Citalopram (brand names: Cipramil, Celapram) · Escitalopram (brand name: Lexapro, Cipralex) · Fluoxetine (brand names: Fluox, Prozac, Apo-fluoxetine, Lovan, Plinzene, Flexetor, Fluohexal) · Fluvoxamine (brand name: Luvox) - not marketed · Paroxetine (brand name: Aropax) · Sertraline (brand name: Zoloft) · Venlafaxine (brand name: Efexor)
Tricyclic antidepressants available in New Zealand are:
Amitriptyline (brand name: Amitrip) . Clomipramine (brand name: Anafranil, Apo-clomipramine, Clopress) . Desipramine (brand name: Pertofran) . Doxepin (brand name: Anten) . Dothiepin (brand name: Dopress) . Imipramine (brand name: Tofranil) . Maprotiline (brand name: Ludiomil) . Mianserin (brand name: Tolvon) . Noritriptyline (brand name: Norpress) . Trimipramine (brand name: Tripress, Surmontil)
Other antidepressants available in New Zealand are:
Mirtazapine (brand name: Remeron) . Moclobemide (brand name: Aurorix, Apo-moclobemide) . Reboxetine (brand name: Edronax) . Tranylcypromine (brand name: Parnate)
Please note, there may be other antidepressant drugs available in NZ that are not listed above.
According to the issue of The Listener published for the week of October 22 - 28, 2011, the prescribing of antidepressants has grown 40% here in the past five years. Pharmac estimates that 400,000 New Zealanders, or 10% of the population, are on antidepressants.
So how does this relate to hyperhidrosis (excessive sweating) and ETS surgery?
Last year, I became aware that the use of antidepressant drugs can cause serotonin syndrome in some individuals. Serotonin syndrome is a potentially life threatening drug reaction that causes the body to have too much serotonin, a chemical produced by nerve cells.
A common symptom of serotonin syndrome is excessive sweating not caused by physical activity.
Other symptoms of serotonin syndrome include:
agitation, diarrhea, fever, mental status changes such as confusion or hypomania, muscle spasms (myoclonus), overactive reflexes (hyperreflexia), shivering, tremor, unco-ordinated movements (ataxia)
If you have taken or are taking an antidepressant drug and have begun to experience excessive sweating, then suspect serotonin syndrome as the cause and seek help from a caring medical professional.
Do not let anyone diagnose you with hyperhidrosis and talk you into having ETS surgery without having investigated the possibility of serotonin syndrome being the cause of your excessive sweating.
The Kiwi ETS Group is aware of at least one New Zealander who had ETS with Dr Murray MacCormick for short-duration, excessive facial sweating that developed in middle-age. After having ETS, the patient went on to develop debilitating compensatory sweating that soaks through their clothes daily - a not uncommon side effect of ETS. An Auckland dermatologist who reviewed the patient's medical history post-ETS surgery concluded that they believed the patient had not been afflicted with hyperhidrosis but had in fact been suffering from serotonin syndrome as a result of the high dose of Aropax (an antidepressant) they had been taking over a two-year period before they had ETS surgery. Other typical symptoms of serotonin syndrome the patient had displayed were tremor and ongoing diarrhea.
A gradual adjustment in the dosage of Aropax this patient was taking, or a change in drug therapy, would likely have addressed the antidepressant side effects (serotonin syndrome) the patient was evidently experiencing. Instead, Dr Murray MacCormick, a private surgeon, diagnosed hyperhidrosis and performed ETS, irreversibly cauterising the patient's nervous system.
ETS is considered an absolute last resort option for someone with primary hyperhidrosis (not this patient) where all other alternative and less invasive treatments have been tried and failed (not this patient).
You can read more about the causes, symptoms, risks of, and treatments for serotonin syndrome here: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004531/
Showing posts with label cause of excessive sweating. Show all posts
Showing posts with label cause of excessive sweating. Show all posts
Thursday, November 3, 2011
Monday, March 14, 2011
Reply to the HDC's decision on our complaint against Murray MacCormick
We felt that the Health and Disability Commissioner's December 2010 decision on our complaint against Auckland ETS surgeon Murray MacCormick warranted a reply. Below is the reply sent to the HDC, Anthony Hill, in early February this year. The Kiwi ETS Group would like to extend heartfelt thanks to those who shared their expertise and assisted with writing this letter.
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“Practices may develop in professions, particularly as to disclosure, not because they serve the interests of the clients, but because they protect the interests or convenience of members of the profession.” (King CJ, in F v. R, 1983. 33 SASR 189 (medical malpractice case))
“Sympathectomy is a last resort.” (Australian Doctor, 15 December, 2006)
Dear Mr Hill,
Your response (dated December 7, 2010) to my complaint on behalf of (name deleted for privacy; hereafter referred to as 'the/this patient') is problematic for a variety of reasons and fails to address key elements of the complaint. I wish to point out material facts and failings in your decision.
First, I protest your choice of ‘expert’.
Second, you have – crucially – failed to note that Dr MacCormick contradicts himself while defending himself: Dr MacCormick defended his diagnosis of primary/idiopathic (lifelong, of unknown cause) hyperhidrosis to your expert, Professor Justin Roake, yet admitted in writing to you that he knows AROPAX (the antidepressant medication the patient was taking at the time of her first consultation with Dr MacCormick) is well known for causing sweating in some patients. That Dr MacCormick is still contradicting himself at this stage is evidence of his incompetence and/or his desire to invent justifications with hindsight.
In a complaint process such as this, your role is to ensure that the public are safe and not exposed to predatory or incompetent practices and practitioners. Your duty of care is to the patient and it should have been within your duty of care to ascertain whether the medical conditions and symptoms of the complainant are related to the elective surgical procedure she was offered as a “treatment of choice”. You failed your duty of care and in your role to ensure that the rights of this patient were upheld, and that her complaint was taken care of fairly.
You have a social responsibility to ensure that others are not exposed to harm, either by Dr MacCormick or other surgeons who offer a seemingly safe procedure that turns out to be something else.
By considering it unfair to call on an expert with background in neurology, you give away the fact that you are not interested in either finding out the truth of this case or protecting the public, as indeed such an expert would have found that the effect of sympathectomy does go well beyond arresting sweating (especially in a patient such as this patient, who already has an autoimmune disease (diabetes) and is, therefore, more vulnerable when it comes to injury to/surgery on the Autonomic Nervous System (ANS)).
By this refusal to face the facts, you betray your role.
Here are my observations and comments on the findings of both you and your expert, Professor Roake.
Diagnosis
Dr MacCormick is not qualified to diagnose hyperhidrosis or depression. He is a vascular surgeon.
Because Dr MacCormick also made a mistake by prescribing a drug post-surgery that could interact with AROPAX (a mistake you and Professor Roake do not consider to be a further sign of his incompetence), it is clear that he had or has very little understanding of drug management of disorders not within his area.
Dr MacCormick was not qualified to make a decision on whether the antidepressant drug that caused this patient's facial sweating could not have been changed for another drug, which she might have tolerated better. This should have been discussed with the patient General Practitioner (who prescribed the antidepressants), or Dr MacCormick could have referred the patient to a psychiatrist with experience of treating depression. This would have been a responsible move by a caring medical professional.
Instead, Dr MacCormick offered an irreversible, destructive surgical procedure on the ANS, causing permanent nerve injury and countless side effects for an already depressed patient, even though Dr MacCormick is aware that even one side effect – compensatory sweating – that is absolutely unpredictable, can cause depression even in previously unaffected individuals.
Neurology and specifically the science of the ANS are not something within the qualifications of Dr MacCormick or Professor Roake, yet they feel authoritative enough to make decisions on who this procedure is safe for and who is a good candidate for the procedure.
“Opinion must be more than “distinguished”. Epistemically warrantable rather that reputationally based.” (Journal of Law and Medicine, 2006. Feb. Vol. 13, No. 3)
I strongly disagree with your expert, Professor Roake, who also is a vascular surgeon with no qualifications in neurology or the function of the ANS, that this patient was a good candidate for sympathectomy. An expert's opinion in the ANS and neurology should have been sought – not only for him/her to establish causation in this case, but to consider what the likely outcome of such intervention would be, and thus, what the patient disclosure should contain in order to qualify as informed consent.
No responsible surgeon – and you can spend many nights going through the scientific literature – will agree with Professor Roake that this patient was a good candidate for this surgery.
ETS is considered an absolute last resort option for someone with primary hyperhidrosis (not this patient) where all other alternative and less invasive treatments have been tried and failed (not this patient).
Primary hyperhidrosis is present from birth or adolescence (not this patient), and is not dependent on triggers such as medication.
No knowledgeable medical professional will agree with you that this patient had primary/idiopathic (of unknown origin) hyperhidrosis – this was Dr MacCormick’s diagnosis, as stated in paragraphs 1and 4 on page 3 of your decision letter dated December 7, 2010 – and the conclusions and credibility of Professor Roake are questionable. Dr MacCormick is not qualified to diagnose primary hyperhidrosis, and he could not have diagnosed primary/idiopathic hyperhidrosis when he freely admits that this patient's facial sweating was likely caused by the antidepressant drugs she was taking. The fact that ETS arrested the facial sweating does not prove Professor Roake’s conclusions; rather it illustrates his incompetence, bias or both. Professor Roake should know that Endoscopic Thoracic Sympathectomy (ETS) will disrupt nerve signals to the sweat glands (among many other structures and organs) and arrest sweating, no matter what the cause. The so-called ‘success’ in this case does not indicate that the patient had primary hyperhidrosis.
In his letter to you, dated 20 August, 2010, Dr MacCormick freely and of his own will admits to having been aware during his first consultation with the patient that she was taking the antidepressant AROPAX, and that he is aware this drug is “well known to cause sweats in susceptible individuals”. In this letter, under the subheading ‘Diagnosis and choice of treatment’, Dr MacCormick listed non-surgical treatment options for facial sweating as a side effect of AROPAX, concluding that these options were “not advisable” and “not .... safe or practical” and ETS could be considered a “treatment of choice”. Dr MacCormick failed his duty of care by offering an irreversible procedure that placed the patient in danger and had a significant chance of severe side effects, even though he knew the patient's facial sweating could be eliminated by a change in medical therapy. This indicates that Dr MacCormick placed his own (financial) interests above the safety and well-being of the patient in his care.
In addition, Dr MacCormick is not qualified to make decisions on various drugs that are on the market to treat sweating. If he feels such drugs are unsafe, harmful to patients, and ineffective, he should have contacted Medsafe to make sure such drugs are removed from the market so that patients are not harmed by using them.
Informed consent
“Known risks should be disclosed when an adverse event is common, even though the detriment is slight, or when an adverse outcome is severe, even though its occurrence is rare.” (National Health and Medical Research Council of Australia, Guidelines, 2004. Para. 1, p. 11)
“The standard for informed consent is that which a reasonable patient might expect rather than what a reasonable doctor might think (Rogers v. Whitaker 1992), and failure to fulfil requirements may be considered as medical misconduct.” (Coles Medical practice in New Zealand, 2011. Chapter 9, p. 88)
Informed consent is at the heart of patient’s right for self-determination, and a violation of this right (by deliberately withholding information that would have been necessary for the patient to form a balanced view of the procedure) is a violation of the patient’s rights, integrity, and the code of the profession.
I have little doubt that Dr MacCormick would have exaggerated the positives of ETS surgery; conclusions can be drawn from comments he made at a 1999 Royal Australasian College of Surgeons conference, which were later published in a major daily Australian newspaper. Please find a copy of the article attached to this letter. In addition, please also see this online article written by Dr MacCormick for the website Family Doctor, where he states that hyperhidrosis is classically a life-long affliction of no known cause (see paragraphs 3 and 6).
“With no underlying clinical need for surgery, and the somewhat entrepreneurial nature of ‘cosmetic/elective’ surgery, there is arguably a greater degree of inherent tension between the wish of the surgeon to sell his or her services, and the more rigorous patient selection required to protect the patient seeking such procedures from misconceived notions as to what may be their benefit.” (Bill Madden: Competence and Irrationality: Locating the Law, Australian Civil Liability, 2006. Vol. 3, No. 5 & 6)
When it comes to elective surgical procedures, it seems likely that disclosure will sometimes fall short of accepted standards. Most ETS surgeons describe their procedure as ‘safe, easy to perform, minimally invasive’, and ‘transforming lives for the better’, with either 100% or 99% effectiveness. This myth is maintained by constant repetition of the fiction. There is no independent scientific evidence in support of these claims. While ETS surgeons describe it as a brilliant ‘cure’, other medical professionals refer to it as having ‘adverse effects that are understated’, and a significant number of ETS patients describe the procedure as ‘the worst mistake of my life’.
You have not provided any evidence that the patient had the information necessary to make an informed choice. Crucially, you have not provided any evidence of the existence of the said “written material” provided to the patient, as stated by Dr MacCormick and Professor Roake, nor have you provided any evidence that the patient was given such a document. Perhaps I should have been provided with Dr MacCormick’s “written material” on ETS so that I could determine if it covers the subject well. I am afraid that if your office received this information, you failed to forward it to me.
In addition, there is no evidence that Dr MacCormick had a lengthy consultation with the patient, taking her medical history, giving a diagnosis, explaining alternative treatments and the pros and cons of each, and then explaining the surgical procedure, possible complications, frequent side effects and less frequent and severe side effects.
“Rogers v Whitaker (1992) 175 CLR 479 High Court Australia decision affirms that a doctor has a duty to warn a patient of any material risk involved in a proposed treatment. A risk is considered material if a reasonable person in similar circumstances would attach significance to the risk, or if the doctor is, or should be, cognizant that the particular patient would express concerns about the risk.” (Coles Medical practice in New Zealand, 2011. Chapter 9, p. 91)
While both Dr MacCormick and your expert are happy to refer to ‘compensatory sweating’ (and no other side effects), you should realise that this name is largely misleading. It is far from ‘compensatory’ and is in fact a symptom of dysautonomia, or deranged function of the ANS.
The question arises: why would Dr MacCormick offer an irreversible surgical procedure to a depressed and vulnerable patient who is stressed over her facial sweating, when he knows all too well that the resultant so-called compensatory sweating can be just as bad, if not worse, for the patient?
“Patients who have a complaint about the care or treatment they have received have a right to a prompt, constructive and honest response, including an explanation and, if appropriate, an apology.” (Good Medical Practice: A guide for doctors, Medical Council of New Zealand, Dealing with adverse outcomes, June 2008. Point 34, p.13 (http://www.mcnz.org.nz/portals/0/guidance/goodmedpractice.pdf))
Dr MacCormick refused to see the patient when she wrote to him in April 2010. I have little doubt that he treats his other unhappy patients who are dissatisfied with the outcome of their procedure in a similar fashion, and refuses to acknowledge some of the severe consequences ETS can have.
It is not in the interest of the patient's emotional wellbeing to meet with Dr MacCormick and his offer to meet in his letter dated August 20, 2010 is 5 years late, and would cause further trauma and have no resolution. There is no doubt that Dr McCormick continues to believe that he behaved and acted in an impeccable professional manner, and your finding just confirms this.
No doubt the offer to meet with the patient (for what purpose?) came only to make him look like a caring doctor. Sadly, the facts do not support this image he so wishes to portray.
Summary
I refuse your finding that the patient was provided “appropriate information”. Appropriate information would have included quotes such as these (or a layman’s version of), and more:
“T(2)–T(3) ganglionectomy significantly decreases pulse rate and systolic blood pressure, reduces myocardial oxygen demand, increases left ventricular ejection fraction and prolongs Q-T interval. A certain loss of lung volume and decrease of pulmonary diffusion capacity for CO result from sympathectomy. Histomorphological muscle changes and neuro-histochemical and biochemical effects have also been observed.” (Clin Auton Res. 2003, Dec; 13 Suppl 1:I40–4)
“Forty-one percent of the participants claimed that their quality of life decreased moderately or severely as a result of Compensatory Sweating.” (J Pediatr Surg. 2007, Jul; 42 7:1238–42)
With no awareness of such information and, therefore, no opportunity to discuss the wide-ranging effects and consequences with Dr MacCormick, the patient was not provided with sufficient information to make an informed choice.
Furthermore, your ruling that it would be “unfair” to consult a neurologist on this case to ascertain causation is unacceptable, irrational and contrary to your duty of care. Indeed, this is the most important point of the case, but your wilful refusal to even consider the implications this surgery might have – and not just for this patient but for many other unsuspecting patients who volunteer to undergo an elective procedure – allows the continuation of this practice to go unchallenged. By refusing to acknowledge the facts and turning away from the problem, you have become part of the problem. Not quite the role the commissioner should play.
For some unexplainable reason, you suggest that the patient should see Dr MacCormick and consult with him on the disabling side effects she now has. The patient approached you to protect her (and others) from medical professionals like Dr MacCormick, and you failed to act on her behalf.
The CONTRA PROFERENTUM rule may be invoked by the patient in interpreting the consent form. According to this rule, if there is any ambiguity in a written document, it should be interpreted against the interest of the person seeking to rely on it – that is, the doctor.
“His Lordship referred to American authorities, such as the decision of the United States Court of Appeals, District of Columbia Circuit, in Canterbury v. Spence ((18) (1972) 464 F 2d 772), and to the decision of the Supreme Court of Canada in Reibl v. Hughes ((19) (1980) 114 DLR (3d) 1), which held that the “duty to warn” arises from the patient’s right to know of material risks, a right which in turn arises from the patient’s right to decide for himself or herself whether or not to submit to the medical treatment proposed.” [ROGERS v. WHITAKER [1992] HCA 58; (1992) 175 CLR 479 F.C. 92/045]
“Given that it is a rarely performed procedure, the number of claims we have experienced appears to be disproportionate. It is a highly elective procedure, so in the event of an adverse outcome, any claim can be difficult to defend. There is also concern that some medical practitioners may be performing Endoscopic Thoracic or Cervical Sympathectomies with little or no specific training in this procedure.” Lyndall Hillbrich, The Medical Defence Association of Victoria Ltd.
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“Practices may develop in professions, particularly as to disclosure, not because they serve the interests of the clients, but because they protect the interests or convenience of members of the profession.” (King CJ, in F v. R, 1983. 33 SASR 189 (medical malpractice case))
“Sympathectomy is a last resort.” (Australian Doctor, 15 December, 2006)
Dear Mr Hill,
Your response (dated December 7, 2010) to my complaint on behalf of (name deleted for privacy; hereafter referred to as 'the/this patient') is problematic for a variety of reasons and fails to address key elements of the complaint. I wish to point out material facts and failings in your decision.
First, I protest your choice of ‘expert’.
Second, you have – crucially – failed to note that Dr MacCormick contradicts himself while defending himself: Dr MacCormick defended his diagnosis of primary/idiopathic (lifelong, of unknown cause) hyperhidrosis to your expert, Professor Justin Roake, yet admitted in writing to you that he knows AROPAX (the antidepressant medication the patient was taking at the time of her first consultation with Dr MacCormick) is well known for causing sweating in some patients. That Dr MacCormick is still contradicting himself at this stage is evidence of his incompetence and/or his desire to invent justifications with hindsight.
In a complaint process such as this, your role is to ensure that the public are safe and not exposed to predatory or incompetent practices and practitioners. Your duty of care is to the patient and it should have been within your duty of care to ascertain whether the medical conditions and symptoms of the complainant are related to the elective surgical procedure she was offered as a “treatment of choice”. You failed your duty of care and in your role to ensure that the rights of this patient were upheld, and that her complaint was taken care of fairly.
You have a social responsibility to ensure that others are not exposed to harm, either by Dr MacCormick or other surgeons who offer a seemingly safe procedure that turns out to be something else.
By considering it unfair to call on an expert with background in neurology, you give away the fact that you are not interested in either finding out the truth of this case or protecting the public, as indeed such an expert would have found that the effect of sympathectomy does go well beyond arresting sweating (especially in a patient such as this patient, who already has an autoimmune disease (diabetes) and is, therefore, more vulnerable when it comes to injury to/surgery on the Autonomic Nervous System (ANS)).
By this refusal to face the facts, you betray your role.
Here are my observations and comments on the findings of both you and your expert, Professor Roake.
Diagnosis
Dr MacCormick is not qualified to diagnose hyperhidrosis or depression. He is a vascular surgeon.
Because Dr MacCormick also made a mistake by prescribing a drug post-surgery that could interact with AROPAX (a mistake you and Professor Roake do not consider to be a further sign of his incompetence), it is clear that he had or has very little understanding of drug management of disorders not within his area.
Dr MacCormick was not qualified to make a decision on whether the antidepressant drug that caused this patient's facial sweating could not have been changed for another drug, which she might have tolerated better. This should have been discussed with the patient General Practitioner (who prescribed the antidepressants), or Dr MacCormick could have referred the patient to a psychiatrist with experience of treating depression. This would have been a responsible move by a caring medical professional.
Instead, Dr MacCormick offered an irreversible, destructive surgical procedure on the ANS, causing permanent nerve injury and countless side effects for an already depressed patient, even though Dr MacCormick is aware that even one side effect – compensatory sweating – that is absolutely unpredictable, can cause depression even in previously unaffected individuals.
Neurology and specifically the science of the ANS are not something within the qualifications of Dr MacCormick or Professor Roake, yet they feel authoritative enough to make decisions on who this procedure is safe for and who is a good candidate for the procedure.
“Opinion must be more than “distinguished”. Epistemically warrantable rather that reputationally based.” (Journal of Law and Medicine, 2006. Feb. Vol. 13, No. 3)
I strongly disagree with your expert, Professor Roake, who also is a vascular surgeon with no qualifications in neurology or the function of the ANS, that this patient was a good candidate for sympathectomy. An expert's opinion in the ANS and neurology should have been sought – not only for him/her to establish causation in this case, but to consider what the likely outcome of such intervention would be, and thus, what the patient disclosure should contain in order to qualify as informed consent.
No responsible surgeon – and you can spend many nights going through the scientific literature – will agree with Professor Roake that this patient was a good candidate for this surgery.
ETS is considered an absolute last resort option for someone with primary hyperhidrosis (not this patient) where all other alternative and less invasive treatments have been tried and failed (not this patient).
Primary hyperhidrosis is present from birth or adolescence (not this patient), and is not dependent on triggers such as medication.
No knowledgeable medical professional will agree with you that this patient had primary/idiopathic (of unknown origin) hyperhidrosis – this was Dr MacCormick’s diagnosis, as stated in paragraphs 1and 4 on page 3 of your decision letter dated December 7, 2010 – and the conclusions and credibility of Professor Roake are questionable. Dr MacCormick is not qualified to diagnose primary hyperhidrosis, and he could not have diagnosed primary/idiopathic hyperhidrosis when he freely admits that this patient's facial sweating was likely caused by the antidepressant drugs she was taking. The fact that ETS arrested the facial sweating does not prove Professor Roake’s conclusions; rather it illustrates his incompetence, bias or both. Professor Roake should know that Endoscopic Thoracic Sympathectomy (ETS) will disrupt nerve signals to the sweat glands (among many other structures and organs) and arrest sweating, no matter what the cause. The so-called ‘success’ in this case does not indicate that the patient had primary hyperhidrosis.
In his letter to you, dated 20 August, 2010, Dr MacCormick freely and of his own will admits to having been aware during his first consultation with the patient that she was taking the antidepressant AROPAX, and that he is aware this drug is “well known to cause sweats in susceptible individuals”. In this letter, under the subheading ‘Diagnosis and choice of treatment’, Dr MacCormick listed non-surgical treatment options for facial sweating as a side effect of AROPAX, concluding that these options were “not advisable” and “not .... safe or practical” and ETS could be considered a “treatment of choice”. Dr MacCormick failed his duty of care by offering an irreversible procedure that placed the patient in danger and had a significant chance of severe side effects, even though he knew the patient's facial sweating could be eliminated by a change in medical therapy. This indicates that Dr MacCormick placed his own (financial) interests above the safety and well-being of the patient in his care.
In addition, Dr MacCormick is not qualified to make decisions on various drugs that are on the market to treat sweating. If he feels such drugs are unsafe, harmful to patients, and ineffective, he should have contacted Medsafe to make sure such drugs are removed from the market so that patients are not harmed by using them.
Informed consent
“Known risks should be disclosed when an adverse event is common, even though the detriment is slight, or when an adverse outcome is severe, even though its occurrence is rare.” (National Health and Medical Research Council of Australia, Guidelines, 2004. Para. 1, p. 11)
“The standard for informed consent is that which a reasonable patient might expect rather than what a reasonable doctor might think (Rogers v. Whitaker 1992), and failure to fulfil requirements may be considered as medical misconduct.” (Coles Medical practice in New Zealand, 2011. Chapter 9, p. 88)
Informed consent is at the heart of patient’s right for self-determination, and a violation of this right (by deliberately withholding information that would have been necessary for the patient to form a balanced view of the procedure) is a violation of the patient’s rights, integrity, and the code of the profession.
I have little doubt that Dr MacCormick would have exaggerated the positives of ETS surgery; conclusions can be drawn from comments he made at a 1999 Royal Australasian College of Surgeons conference, which were later published in a major daily Australian newspaper. Please find a copy of the article attached to this letter. In addition, please also see this online article written by Dr MacCormick for the website Family Doctor, where he states that hyperhidrosis is classically a life-long affliction of no known cause (see paragraphs 3 and 6).
“With no underlying clinical need for surgery, and the somewhat entrepreneurial nature of ‘cosmetic/elective’ surgery, there is arguably a greater degree of inherent tension between the wish of the surgeon to sell his or her services, and the more rigorous patient selection required to protect the patient seeking such procedures from misconceived notions as to what may be their benefit.” (Bill Madden: Competence and Irrationality: Locating the Law, Australian Civil Liability, 2006. Vol. 3, No. 5 & 6)
When it comes to elective surgical procedures, it seems likely that disclosure will sometimes fall short of accepted standards. Most ETS surgeons describe their procedure as ‘safe, easy to perform, minimally invasive’, and ‘transforming lives for the better’, with either 100% or 99% effectiveness. This myth is maintained by constant repetition of the fiction. There is no independent scientific evidence in support of these claims. While ETS surgeons describe it as a brilliant ‘cure’, other medical professionals refer to it as having ‘adverse effects that are understated’, and a significant number of ETS patients describe the procedure as ‘the worst mistake of my life’.
You have not provided any evidence that the patient had the information necessary to make an informed choice. Crucially, you have not provided any evidence of the existence of the said “written material” provided to the patient, as stated by Dr MacCormick and Professor Roake, nor have you provided any evidence that the patient was given such a document. Perhaps I should have been provided with Dr MacCormick’s “written material” on ETS so that I could determine if it covers the subject well. I am afraid that if your office received this information, you failed to forward it to me.
In addition, there is no evidence that Dr MacCormick had a lengthy consultation with the patient, taking her medical history, giving a diagnosis, explaining alternative treatments and the pros and cons of each, and then explaining the surgical procedure, possible complications, frequent side effects and less frequent and severe side effects.
“Rogers v Whitaker (1992) 175 CLR 479 High Court Australia decision affirms that a doctor has a duty to warn a patient of any material risk involved in a proposed treatment. A risk is considered material if a reasonable person in similar circumstances would attach significance to the risk, or if the doctor is, or should be, cognizant that the particular patient would express concerns about the risk.” (Coles Medical practice in New Zealand, 2011. Chapter 9, p. 91)
While both Dr MacCormick and your expert are happy to refer to ‘compensatory sweating’ (and no other side effects), you should realise that this name is largely misleading. It is far from ‘compensatory’ and is in fact a symptom of dysautonomia, or deranged function of the ANS.
The question arises: why would Dr MacCormick offer an irreversible surgical procedure to a depressed and vulnerable patient who is stressed over her facial sweating, when he knows all too well that the resultant so-called compensatory sweating can be just as bad, if not worse, for the patient?
“Patients who have a complaint about the care or treatment they have received have a right to a prompt, constructive and honest response, including an explanation and, if appropriate, an apology.” (Good Medical Practice: A guide for doctors, Medical Council of New Zealand, Dealing with adverse outcomes, June 2008. Point 34, p.13 (http://www.mcnz.org.nz/portals/0/guidance/goodmedpractice.pdf))
Dr MacCormick refused to see the patient when she wrote to him in April 2010. I have little doubt that he treats his other unhappy patients who are dissatisfied with the outcome of their procedure in a similar fashion, and refuses to acknowledge some of the severe consequences ETS can have.
It is not in the interest of the patient's emotional wellbeing to meet with Dr MacCormick and his offer to meet in his letter dated August 20, 2010 is 5 years late, and would cause further trauma and have no resolution. There is no doubt that Dr McCormick continues to believe that he behaved and acted in an impeccable professional manner, and your finding just confirms this.
No doubt the offer to meet with the patient (for what purpose?) came only to make him look like a caring doctor. Sadly, the facts do not support this image he so wishes to portray.
Summary
I refuse your finding that the patient was provided “appropriate information”. Appropriate information would have included quotes such as these (or a layman’s version of), and more:
“T(2)–T(3) ganglionectomy significantly decreases pulse rate and systolic blood pressure, reduces myocardial oxygen demand, increases left ventricular ejection fraction and prolongs Q-T interval. A certain loss of lung volume and decrease of pulmonary diffusion capacity for CO result from sympathectomy. Histomorphological muscle changes and neuro-histochemical and biochemical effects have also been observed.” (Clin Auton Res. 2003, Dec; 13 Suppl 1:I40–4)
“Forty-one percent of the participants claimed that their quality of life decreased moderately or severely as a result of Compensatory Sweating.” (J Pediatr Surg. 2007, Jul; 42 7:1238–42)
With no awareness of such information and, therefore, no opportunity to discuss the wide-ranging effects and consequences with Dr MacCormick, the patient was not provided with sufficient information to make an informed choice.
Furthermore, your ruling that it would be “unfair” to consult a neurologist on this case to ascertain causation is unacceptable, irrational and contrary to your duty of care. Indeed, this is the most important point of the case, but your wilful refusal to even consider the implications this surgery might have – and not just for this patient but for many other unsuspecting patients who volunteer to undergo an elective procedure – allows the continuation of this practice to go unchallenged. By refusing to acknowledge the facts and turning away from the problem, you have become part of the problem. Not quite the role the commissioner should play.
For some unexplainable reason, you suggest that the patient should see Dr MacCormick and consult with him on the disabling side effects she now has. The patient approached you to protect her (and others) from medical professionals like Dr MacCormick, and you failed to act on her behalf.
The CONTRA PROFERENTUM rule may be invoked by the patient in interpreting the consent form. According to this rule, if there is any ambiguity in a written document, it should be interpreted against the interest of the person seeking to rely on it – that is, the doctor.
“His Lordship referred to American authorities, such as the decision of the United States Court of Appeals, District of Columbia Circuit, in Canterbury v. Spence ((18) (1972) 464 F 2d 772), and to the decision of the Supreme Court of Canada in Reibl v. Hughes ((19) (1980) 114 DLR (3d) 1), which held that the “duty to warn” arises from the patient’s right to know of material risks, a right which in turn arises from the patient’s right to decide for himself or herself whether or not to submit to the medical treatment proposed.” [ROGERS v. WHITAKER [1992] HCA 58; (1992) 175 CLR 479 F.C. 92/045]
“Given that it is a rarely performed procedure, the number of claims we have experienced appears to be disproportionate. It is a highly elective procedure, so in the event of an adverse outcome, any claim can be difficult to defend. There is also concern that some medical practitioners may be performing Endoscopic Thoracic or Cervical Sympathectomies with little or no specific training in this procedure.” Lyndall Hillbrich, The Medical Defence Association of Victoria Ltd.
Monday, January 31, 2011
HDC decision on complaint against Auckland ETS surgeon Dr Murray MacCormick
In December 2010, we were informed by letter that New Zealand's Health and Disability Commissioner, Anthony Hill, had found in favour of Dr Murray MacCormick.
Here are links to the HDC's decision letter (one link leads to one scanned page, so five pages/links in total):
page 1
page 2
page 3
page 4
page 5
Note the commissioner's comment on page 4 about how it would be "unfair" for him to request advice from a neurologist!
And here are links to the earlier letter that Dr MacCormick sent to the HDC when they approached him to hear his side (two links to two scanned pages):
page 1
page 2
The expert chosen to aid the HDC's investigation in the case, Professor Justin Roake, is a vascular surgeon who works at a private practice in Christchurch, New Zealand, that offers Endoscopic Thoracic Sympathectomy (ETS).
ETS is, in best practice, supposed to be a last resort treatment for those with primary (lifelong, of unknown cause) hyperhidrosis, when all other treatments have been tried and failed. Even then, it is a surgery that comes with a significant risk of adverse side effects.
The New Zealand ETS patient who this complaint was made on behalf of never actually had primary hyperhidrosis. She was simply suffering short-term (duration two years approx. in middle age) excessive facial sweating, and other problems such as tremors, as side effects of the high dose of the antidepressant AROPAX she was taking in 2004/2005. The failure to realise this on the part of her prescribing GP, Dr Paul Fur, who referred her to Dr MacCormick, is disturbing. And Dr MacCormick's behaviour - in offering this patient ETS and describing it as a "treatment of choice" while acknowledging in his letter to the HDC that AROPAX is "well known to cause sweats in susceptible individuals" - speaks for itself.
The patient feels that her already severe Compensatory Sweating (CS) - a common adverse side effect of ETS - is getting worse: she gets soaked in sweat from her chest to knees daily in warm and hot weather. In addition, she has been experiencing other health issues that may be related to ETS. She has spoken several times of how she has contemplated ending her life because of how the CS has affected everything - her professional life, her social life, her quality of life.
Any New Zealand ETS patients contemplating making a formal complaint about your ETS surgeon, please feel free to reference this complaint in support of your own. The reference number is: C10HDC00679
The outcome of this complaint has been disappointing, to say the least. But it has created a paper trail that other New Zealand ETS patients can reference and use as a resource when making their own complaints.
It is vitally important that ETS patients suffering from the devastating side effects of this elective surgery make formal complaints about their surgeons who did not disclose during pre-surgery consultations the many frequent and less frequent adverse side effects of ETS. Eventually, the number of complaints will add up, and the authorities will be forced to act.
In the mean time, we have the power of the Internet. In the case of this recent complaint, the HDC did not even come close to 1) ensuring that the rights of the patient were upheld, and 2) investigating the complaint fairly - as is the Commissioner's role. However, this does not mean the Kiwi ETS Group has failed. We are still here and we are still one of several voices on the Internet warning those considering ETS surgery that the outcome of ETS surgery is often nothing like what your surgeon will promise you. This irreversible surgery does leave a significant number of patients with serious health issues that have devastating, life-changing effects, such as bradycardia, severe compensatory sweating, ongoing neuropathic pain, erectile dysfunction, and anhidrosis and the associated impaired thermoregulation, to name but a few severe and not uncommon side effects.
The wealth of published medical research on sympathectomies supports this truth, as do the testimonies of the many suffering patients. While those in power might currently choose to look the other way, they cannot silence either these testimonies or the medical research documenting the risks of ETS.
Here are links to the HDC's decision letter (one link leads to one scanned page, so five pages/links in total):
page 1
page 2
page 3
page 4
page 5
Note the commissioner's comment on page 4 about how it would be "unfair" for him to request advice from a neurologist!
And here are links to the earlier letter that Dr MacCormick sent to the HDC when they approached him to hear his side (two links to two scanned pages):
page 1
page 2
The expert chosen to aid the HDC's investigation in the case, Professor Justin Roake, is a vascular surgeon who works at a private practice in Christchurch, New Zealand, that offers Endoscopic Thoracic Sympathectomy (ETS).
ETS is, in best practice, supposed to be a last resort treatment for those with primary (lifelong, of unknown cause) hyperhidrosis, when all other treatments have been tried and failed. Even then, it is a surgery that comes with a significant risk of adverse side effects.
The New Zealand ETS patient who this complaint was made on behalf of never actually had primary hyperhidrosis. She was simply suffering short-term (duration two years approx. in middle age) excessive facial sweating, and other problems such as tremors, as side effects of the high dose of the antidepressant AROPAX she was taking in 2004/2005. The failure to realise this on the part of her prescribing GP, Dr Paul Fur, who referred her to Dr MacCormick, is disturbing. And Dr MacCormick's behaviour - in offering this patient ETS and describing it as a "treatment of choice" while acknowledging in his letter to the HDC that AROPAX is "well known to cause sweats in susceptible individuals" - speaks for itself.
The patient feels that her already severe Compensatory Sweating (CS) - a common adverse side effect of ETS - is getting worse: she gets soaked in sweat from her chest to knees daily in warm and hot weather. In addition, she has been experiencing other health issues that may be related to ETS. She has spoken several times of how she has contemplated ending her life because of how the CS has affected everything - her professional life, her social life, her quality of life.
Any New Zealand ETS patients contemplating making a formal complaint about your ETS surgeon, please feel free to reference this complaint in support of your own. The reference number is: C10HDC00679
The outcome of this complaint has been disappointing, to say the least. But it has created a paper trail that other New Zealand ETS patients can reference and use as a resource when making their own complaints.
It is vitally important that ETS patients suffering from the devastating side effects of this elective surgery make formal complaints about their surgeons who did not disclose during pre-surgery consultations the many frequent and less frequent adverse side effects of ETS. Eventually, the number of complaints will add up, and the authorities will be forced to act.
In the mean time, we have the power of the Internet. In the case of this recent complaint, the HDC did not even come close to 1) ensuring that the rights of the patient were upheld, and 2) investigating the complaint fairly - as is the Commissioner's role. However, this does not mean the Kiwi ETS Group has failed. We are still here and we are still one of several voices on the Internet warning those considering ETS surgery that the outcome of ETS surgery is often nothing like what your surgeon will promise you. This irreversible surgery does leave a significant number of patients with serious health issues that have devastating, life-changing effects, such as bradycardia, severe compensatory sweating, ongoing neuropathic pain, erectile dysfunction, and anhidrosis and the associated impaired thermoregulation, to name but a few severe and not uncommon side effects.
The wealth of published medical research on sympathectomies supports this truth, as do the testimonies of the many suffering patients. While those in power might currently choose to look the other way, they cannot silence either these testimonies or the medical research documenting the risks of ETS.
Monday, April 12, 2010
NZ ETS patient makes official complaint about their surgeon
A New Zealand ETS patient has just begun the process of making a complaint about their ETS surgeon, Dr Murray MacCormick, to the Health and Disability Commissioner (HDC).
Updates on how the complaint progresses will be posted here. The Kiwi ETS Group has written a letter in support of this ETS patient to the HDC, highlighting the fact that several New Zealand ETS patients we have had contact with are dissatisified patients of Dr MacCormick because of the disabling and devastating side effects their ETS surgeries have left them with - side effects Dr MacCormick never warned them about or downplayed the likelihood/severity of.
In addition, the letter highlights the following issues with Dr MacCormick's decision to offer ETS to this patient.
1.) The patient was suffering from excessive facial sweating as a side effect of medication they were taking. However, at that time, the patient was not aware what was causing the excessive facial sweating - after all, they are not a medical professional.
You would think that in such a case, an experienced doctor, which Dr MacCormick indeed is, would extensively question the patient about their medical history, any medication they were taking, and how long the sweating had been a problem for, and use their medical knowledge to determine that the sweating was not actually hyperhidrosis but a far simpler problem that could easily be alleviated by adjusting or changing the patient's medication.
Instead, within the space of a 15-minute consultation - the first ever consultation between Dr MacCormick and this patient - the doctor recommended ETS to treat the excessive facial sweating and scheduled the surgery to take place within the week.
2.) Even IF the patient had indeed had facial hyperhidrosis, ETS surgery is suppposed to be a last resort treatment for hyperhidrosis when all other non-surgical treatment options have been tried, and have failed. However, as the patient did not even have hyperhidrosis, they should never have been considered a candidate for ETS.
The letter also points out that Dr MacCormick, as a private practitioner, made a sizable sum of money from performing the ETS surgery on this patient.
The patient now lives with disabling severe CS and other side effects commonly reported by ETS patients - ongoing fatigue, painfully dry skin on the arms and mysterious pains in the limbs and extremities.
This patient's story is one of the most shocking we have heard to date about ETS in New Zealand.
If you are a dissatisfied past patient of Dr Murray MacCormick, now would be a good time to make your dissatisfaction known to the Health and Disability Commissioner. The higher the number of distressed patients, the harder it will be for the HDC to take the issue lightly.
Updates on how the complaint progresses will be posted here. The Kiwi ETS Group has written a letter in support of this ETS patient to the HDC, highlighting the fact that several New Zealand ETS patients we have had contact with are dissatisified patients of Dr MacCormick because of the disabling and devastating side effects their ETS surgeries have left them with - side effects Dr MacCormick never warned them about or downplayed the likelihood/severity of.
In addition, the letter highlights the following issues with Dr MacCormick's decision to offer ETS to this patient.
1.) The patient was suffering from excessive facial sweating as a side effect of medication they were taking. However, at that time, the patient was not aware what was causing the excessive facial sweating - after all, they are not a medical professional.
You would think that in such a case, an experienced doctor, which Dr MacCormick indeed is, would extensively question the patient about their medical history, any medication they were taking, and how long the sweating had been a problem for, and use their medical knowledge to determine that the sweating was not actually hyperhidrosis but a far simpler problem that could easily be alleviated by adjusting or changing the patient's medication.
Instead, within the space of a 15-minute consultation - the first ever consultation between Dr MacCormick and this patient - the doctor recommended ETS to treat the excessive facial sweating and scheduled the surgery to take place within the week.
2.) Even IF the patient had indeed had facial hyperhidrosis, ETS surgery is suppposed to be a last resort treatment for hyperhidrosis when all other non-surgical treatment options have been tried, and have failed. However, as the patient did not even have hyperhidrosis, they should never have been considered a candidate for ETS.
The letter also points out that Dr MacCormick, as a private practitioner, made a sizable sum of money from performing the ETS surgery on this patient.
The patient now lives with disabling severe CS and other side effects commonly reported by ETS patients - ongoing fatigue, painfully dry skin on the arms and mysterious pains in the limbs and extremities.
This patient's story is one of the most shocking we have heard to date about ETS in New Zealand.
If you are a dissatisfied past patient of Dr Murray MacCormick, now would be a good time to make your dissatisfaction known to the Health and Disability Commissioner. The higher the number of distressed patients, the harder it will be for the HDC to take the issue lightly.
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